Acute Inpatient Rehabilitation denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement and prospective authorization and coverage for acute rehabilitation services, or in the alternative, skilled nursing facility (SNF) level of care services. The records indicate that this patient has a history of diabetes mellitus type II, hypertension, and chronic kidney disease. The patient was admitted to the hospital for a stroke with left-sided hemiparesis, dysarthria, and dysphagia due to an occlusion of the right posterior cerebral artery. The patient underwent a thrombectomy and the hospital stay was notable for a urinary tract infection requiring antibiotics. The patient was admitted to acute inpatient rehabilitation. The patient’s acute inpatient rehabilitation stay was notable for acute diverticulitis, and he was started on prophylactic antibiotics.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for transfer to an acute inpatient rehabilitation hospital and/or acute rehabilitation with the use of a Zero-G robotic body weight support system. This patient presents with hemiplegia and hemiparesis following cerebral infarction. Ischemic stroke is caused by arterial occlusion and is responsible for the majority of strokes. As a result of the stroke, the patient has right hemiplegia, aphasia, dysphasia, neurocognitive deficits, and mild right-side inattention. Per the documentation provided, the patient continues to have decreased mobility, deficits with balance and strength and is unable to independently complete activities of daily living. The patient has been participating in physical therapy and has demonstrated improvement.

Where the denial was upheld

Findings: The physician reviewer found that a patient has requested reimbursement and prospective authorization and coverage for continued inpatient level of care services, or in the alternative, acute rehabilitation services.Admission to an inpatient rehabilitation facility is intended to provide intensive rehabilitation therapy in a resource-intensive inpatient hospital environment for patients who have complex nursing and rehabilitation needs and require the medical management of a rehabilitation physician at least three days per week. Patients are expected to benefit from an inpatient stay and an interdisciplinary team approach to the delivery of rehabilitation care. This treatment plan includes ongoing treatment by physical and occupational therapies and speech-language pathology.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for acute rehabilitation from a facility accredited by the Commission on Accreditation of Rehabilitation Facilities to treat spinal cord injury, that include the following comprehensive, interdisciplinary system integrating services: recreational therapy, participation in wheelchair sports, robotic assisted rehabilitation, rehabilitation with the Lokomat, rehabilitation with an exoskeleton, wheelchair evaluation, selection and fitting, bone loss class/education, gait analysis, respiratory training, simulated home living experience with caregiver training, transitional care between inpatient, outpatient, and wellness center, discharge plans with integration/consideration of social support and the assistance as needed/available at home, vocational re-integration programs/classes, classes on pres…

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving Acute Inpatient Rehabilitation, then check the rights and deadlines that apply to your plan.